The Transition Towards High Value Healthcare

Do Providers vs Payers forms a dichotomy in healthcare?

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"Clinicians must lead efforts to maximize high-value care. If they fail to do so, then ...... may cause governments to consider severe cost-cutting measures, rationing of services, cumbersome remuneration formulas and major limits to professional autonomy..." (Ian Scott, 2014. Ten clinician-driven strategies for maximizing the value of Australian health care). Though the above statement comes from an Australian study and sounds more like a warning and prophecy, the feared outcome by the author, is perhaps a real and sad situation now, at least in some countries.

What is High-Value Healthcare?

Value is an economic concept, and, refers to the utility of service, as assessed by the consumer or payer. Services that are judged to have "High" value by consumers and payers are most likely to be happily accepted by both of them.

Any healthcare that increases life expectancy is generally considered high-value care.

Any healthcare that only improves the quality of life and does not prolong life, may be judged as either high or low, by different stakeholders or in different situations.

The last situation, when healthcare neither increases the quantity, nor the quality of life is often judged as low-value care. Services that are judged to have "Low" value would at least be questioned, if not opposed.

Challenges in Transition to High-Value Healthcare

Providers vs Payers

In historical times, consumers and payers in healthcare were one and the same, but, is no longer the case, as most consumers pay only the premiums for the insurance, and the collected money is handled and released by the insurer. The insurer has to use this money judiciously so that he can serve the best interests of all its members. So, it is quite logical, that insurers would like to support all healthcare, that is high value, and discourage all healthcare that is low value. Payers generally consider that clinical care as high-value care, which has high quality, proven benefits and which comes at a reasonable cost.

Doctors or healthcare providers, on the other hand, may see healthcare as a service, rendered to a patient, so as to make him feel comfortable and free of complaints which caused the patient to avail of their service. Healthcare providers, are accountable to patients and may use off label medicines, or treatments that are currently not well recognized as standard treatments. So, sometimes, in pursuit of the above objective of addressing patient complaints, providers may provide services, that may be assessed as low value as by the payer.

Operational Challenges

There are many issues that create roadblocks, for payers and providers, in the process of transition to high-value healthcare. The transition to a value-based system has been particularly hard to implement because both quality and cost are difficult to quantify.

With recent medical advancements, a major achievement has been the ability of medical testing to identify diseases sufficiently early, in the time-course of their evolution. But, no testing is 100 percent perfect, and in cases, false positive and false negative results compound the picture. Some of the testing like tissue diagnosis may be invasive, and may, in fact, harm a small number of healthy individuals.

Even though professional associations provide guidelines in black and white, on many issues for clinicians, in practice they are seldom put into practice, as the providers focus on delivering the best patient-centered medical care.

Way Forward

I would like to quote here an old study published in 1997, that still seems very relevant: "Not only must providers be able to provide high-quality acute and chronic care, but they must also begin to focus more heavily on programs of prevention. Value is created throughout the system by reducing the prevalence and incidence of disease. Only through managing the full continuum of health will value be created throughout the healthcare delivery system. Outcomes management ensures that the outcomes are the highest quality at a cost-effective price. Outcomes must not only be compared to best practices, but to what is possible. Providers must constantly strive to enhance the quality of the services. Financial/cost management ensures that care is cost-effective and that a marginal profit is maintained to allow continued investment in new technology and continuing medical education to enhance the quality of care and lifestyles for all stakeholders."

Another recent Canadian study puts it in other words but with a very similar message "The shift that from the current state (fragmented, episodic, reactive care) to future state (coordinated, continuous, proactive care) is needed across the health system."

About the author: Dr. Naval Asija is a licensed MBBS Physician from India. MBBS is the equivalent of the MD degree offered by international medical schools. He is based in Delhi, India, and works as a medical writer, editor, and consultant. He supports medical researches as an author's editor, medical communication companies involved in medico-marketing activities, and medical technology companies in improving their products. He can be contacted via his LinkedIn Profile: https://www.linkedin.com/in/navalasija/

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